Formation and regrowth of intra-abdominal adhesions after adhesiolysis: the paradox of surgical adhesion-reduction strategies.

Accessible online at: www.karger.com/dsu We have followed with interest the publications of Swank et al. [1] concerning surgical adhesion-reduction strategies for the management of pelvic pain and wish to respond to their latest article, published in January 2004, which discusses the incidence/ extent of intra-abdominal adhesion formation/reformation following laparoscopic adhesiolysis. The role of intra-abdominal adhesions in the development of chronic pelvic pain remains a matter of debate [2]. Similarly, the efficacy of surgical adhesion-reduction strategies for pain management has been disputed for some time [2]. This article adds to the growing body of evidence in favour of a link between adhesions and pelvic pain [3] and provides an important discussion of the merits of adhesiolytic strategies. In two previous publications, the authors highlight the high risks of bowel perforation associated with adhesiolysis [4, 5] and the lack of difference in pain scores between patients managed by diagnostic laparoscopy or adhesiolytic laparoscopy [5]. In the later publication [5], the authors conclude that diagnostic laparoscopy is invaluable for identifying causes of pelvic pain, but warn that laparoscopic adhesiolysis is associated with considerable morbidity and is no more beneficial than diagnostic laparoscopy for pain relief. In the present article, the authors argue that laparoscopic adhesiolysis significantly reduces the incidence, extent and severity of adhesions between peritoneal organs and the abdominal wall, and suggest that laparoscopy is less adhesiogenic than laparotomy, as has been asserted elsewhere [6]. However, they show no significant reduction in the quantity/quality of adhesions between organs and state that de novo adhesion formation occurred in 20% of patients. Although the patient cohort was small (n = 24), these data, in conjunction with their previous findings, highlight the limitations of surgical adhesion management strategies and emphasise the paradox that adhesiolysis may initiate adhesion development. Numerous studies have drawn attention to the adhesive burden associated with open abdominal surgery [3, 7]. In our own investigations in the Surgical and Clinical Adhesions Research (SCAR) [8] and the more recent SCAR-2 [9, 10] studies, we have revealed the considerable burden and risk of adhesions following both laparoscopic and open abdominopelvic surgery. We believe that, in the context of these studies, the findings presented here highlight the importance of preventive rather than curative strategies for adhesion control. By employing good surgical techniques and adhesion-reduction agents in concert with appropriate, minimally invasive access techniques, we may help to reduce this burden and minimise the risks of chronic pain, as well as small bowel obstruction, in patients who have undergone abdominopelvic surgery.